Can you remember the first time you had to stand up in front of everyone and give a speech at school? That was an anxiety-provoking event for almost anyone, but for some, that anxiety was crushing. The fear was not just of embarrassment but one of deep humiliation. Some don’t just have butterflies in the stomach, but rather, they have shaking hands, quivering voices, sweating, or a flushed face. Some people recount the speech over and over again, reliving each perceived mistake. They might have felt so small that they just wanted to disappear. Now imagine feeling that way all the time in every social situation. What would the experience of not being able to escape the fear, constant threat of failure, sense of scrutiny, fear of humiliation, and shame feel like?
For people with generalized social anxiety disorder (SAD), that is what every day feels like. Social activities may be curtailed altogether or they might push themselves to keep engaging despite the constant self-doubt, self-consciousness, and self-criticism. Living in a state of perpetual anxiety and fear of not being accepted by others is exhausting. Sometimes the social isolation and shame build and turn into depression. Many people with SAD turn to alcohol to cope with anxiety and develop an addiction.
SAD is very common; about 1 in 14 Americans, about 23 million people, suffer from SAD at any given time. SAD is likely even more common right now as people start to emerge from the isolation of the COVID-19 pandemic. Many people aren’t aware that SAD is the fourth most common psychiatric disorder in the USA behind major depression disorder, alcohol use disorders (both of which SAD often contributes), and specific phobias (e.g. fear of heights).
Research shows that many people never seek out treatment for SAD, especially if they identify within a marginalized or oppressed group. Among those who do seek out treatment, only a minority of people ever receive evidence-based treatments and even those treatments may only result in partial recovery. We need better and more accessible treatments for SAD.
Our team at the Portland Psychotherapy Clinic, Research, & Training Center is poised to begin our clinical trial of MDMA-assisted therapy (MDMA-AT) for SAD with the hope it may be able to fill that gap. MDMA-AT has already shown promise in a pilot placebo-controlled clinical trial treating social anxiety in 12 autistic people (Danforth et al., 2018). This initial study found very large effects for MDMA-AT compared to the placebo condition. Other researchers have begun to examine how another psychedelic, the brewed beverage known as Ayahuasca, can help people with social anxiety (dos Santos et al., 2022). Even though the results were promising, the number of people studied is still small, so more research is needed. That is why we are about to begin the first clinical trial investigating the effectiveness of MDMA-AT for SAD in the general population. Based on our review of the literature, I’ve listed some ideas below of how we think MDMA might help enhance therapy for people who are suffering from SAD.
It is posited that some of the effects of MDMA is caused by the release of high levels of “social neurohormones” such as oxytocin, prolactin, and vasopressin (Feduccia & Mithoefer, 2018). These hormones are central to the process of social bonding and feelings of safety around other people. For example, mothers express high levels of oxytocin in the critical hours after birth when bonding begins with their infant. Safety is not something individuals with SAD often feel around others. Instead, they often fear that if they reveal their authentic self, they will be humiliated and rejected by others. Through stimulating these social neurohormones, MDMA seems to help people feel safe enough to be able to be themselves and to engage with their therapists in more genuine and authentic ways, which we know is an essential element of effective therapy. This therapeutic process can also help individuals with SAD build new associations where authenticity is associated with safety and acceptance rather than fear and shame (Luoma et al., 2021). Our research seeks to examine whether MDMA-AT can help people with SAD feel safer to be their genuine selves and at ease in social situations.
MDMA may also be effective in that it often creates an emotional experience of peace, acceptance, and empathy. In contrast, people with SAD are typically highly self-critical and believe that others also see them as not being enough or inadequate. Try to imagine for a moment that you are someone who tends to be very hard on yourself, feeling like you are always falling short. You might feel constantly on guard, self-conscious, and unsure of whether others will accept you. You might feel different, inferior, and inadequate – and you might feel shame, so much shame at all the social failure and losses. Imagine this experience has gone on for years without ceasing. See if you can take a moment to really imagine what this would be like. Now imagine there’s a day, just one day, where you have a deep and abiding experience of acceptance toward yourself and from others. Imagine that, for hours on end, you feel understood by others; like you belong and are accepted just the way you are. What difference might that make? What possibilities might that open up for you if you were able to tap into a part of yourself that was capable of self-compassion and warmth toward yourself? What might it be like to have felt accepted, really accepted, by someone for the first time? Research indicates that MDMA-assisted therapy does this for some people (Frye et al., 2014; Jungaberle et al., 2018; Luoma & Lear, 2021). We’re aiming to study how often and how much of a difference this treatment can make in the lives of people with SAD (Luoma & Lear, 2021).
It is essential to note that a safe, ethical, and supportive therapeutic context makes this change possible, not just the medicine by itself. It’s also important to note that in our studies, MDMA isn’t taken on a daily basis like most antidepressants. Instead, it’s given a handful of times in the context of careful preparation, support, and integration guided by skilled therapists. In addition, while the description above may sound pleasant, the therapy is also usually hard work. The therapists help create a safe container for the experience and help process the shame that may arise when talking about past experiences of social failure. They provide guidance during difficult periods and help the client integrate insights from the MDMA sessions to work in their lives. But ultimately, it’s the client that goes on the journey, who confronts their fears of rejection and inadequacy, and who takes the risk to open up to self-compassion and belonging.
Our research journey is only beginning. Our first step is to complete a waitlist controlled randomized clinical trial with 20 volunteers with social anxiety disorder (https://clinicaltrials.gov/ct2/show/NCT05138068). This trial began recruitment in April 2022 and finished by 2024. From there, we plan to move toward larger trials that will allow more definitive answers. It’s only with the courage of our participants, the support of donors, the skill of our therapists, and the careful collaboration of scientists that we can continue to advance this research and help more people who are struggling with social anxiety. If you want to learn more about this research, please go to: www.portlandmdmatherapy.com.
Danforth, A. L., Grob, C. S., Struble, C., Feduccia, A. A., Walker, N., Jerome, L., Yazar-Klosinski, B., & Emerson, A. (2018). Reduction in social anxiety after MDMA-assisted psychotherapy with autistic adults: A randomized, double-blind, placebo-controlled pilot study. Psychopharmacology, 235(11), 3137–3148. https://doi.org/10.1007/s00213-018-5010-9
Dos Santos, R. G., de Lima Osório, F., Rocha, J. M., Rossi, G. N., Bouso, J. C., Rodrigues, L. S., … & Hallak, J. E. C. (2021). Ayahuasca Improves Self-perception of Speech Performance in Subjects With Social Anxiety Disorder: A Pilot, Proof-of-Concept, Randomized, Placebo-Controlled Trial. Journal of clinical psychopharmacology, 41(5), 540-550.
Feduccia, A. A., & Mithoefer, M. C. (2018). MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? Progress in Neuro-Psychopharmacology and Biological Psychiatry, 84, 221–228.
Frye, C. G., Wardle, M. C., Norman, G. J., & De Wit, H. (2014). MDMA decreases the effects of simulated social rejection. Pharmacology Biochemistry and Behavior, 117, 1–6.
Jungaberle, H., Thal, S., Zeuch, A., Rougemont-Bücking, A., von Heyden, M., Aicher, H., & Scheidegger, M. (2018). Positive psychology in the investigation of psychedelics and entactogens: A critical review. Neuropharmacology, 142, 179-199.
Luoma, J.B. Shahar, B., Lear, M.K., Pilecki, B., & Wagner, A. (2021). Potential Processes of Change in MDMA-Assisted Therapy for Social Anxiety Disorder During Acute Dosing: Enhanced Memory Reconsolidation, Self-Transcendence, and Enhanced Therapeutic Relationship. Human Psychopharmacology, e2824.
Luoma, J.B. & Lear, M.K. (in press). MDMA-Assisted Therapy as a Means to Alter Affective, Cognitive, Behavioral, and Neurological Systems Underlying Social Dysfunction in Social Anxiety Disorder. Frontiers in Psychiatry, 12, 733893.
Jason Luoma, Ph.D., is CEO of Portland Psychotherapy Clinic, Research, & Training Center in Portland, OR, a unique social enterprise that funds research. His research focuses on shame, self-stigma, connection, and the application of Acceptance and Commitment Therapy (ACT) and psychedelic-assisted therapy as an intervention for treating shame and increasing self-compassion. He is currently conducting a clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that is one of the first trials of psychedelic-assisted therapy in the Pacific Northwest. He’s an internationally recognized trainer in ACT, former chair of the ACT training committee, and past president of the Association for Contextual Behavioral Science. He has over 70 publications including two books: Learning Acceptance and Commitment Therapy and Values in Therapy: A Clinician’s Guide to Helping Clients Explore Values, Increase Psychological Flexibility, and Live a More Meaningful Life. His work on shame and compassion can be read at www.actwithcompassion.com.